Breast Reduction

Breast Reduction

Leroy V. Young MD

Marla E. Watson MA

The American Society of Plastic Surgeons (ASPS) defines reconstructive surgery as being “performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance” (1). According to this definition, reduction mammoplasty is considered reconstructive in nature. Yet, aesthetic concerns play important roles in the motivations for surgery as well as postoperative satisfaction.

Women who suffer from breast hypertrophy—unusually large breast size in proportion to the rest of the body—fall into two broad categories: younger women and postmenopausal women (2). In younger women, enlarged breasts most often result from juvenile hypertrophy or obesity. Juvenile hypertrophy is relatively uncommon in the general population and the etiology is unknown. Nevertheless, these patients present to the plastic surgeon with some regularity. Some believe abnormally high levels of estrone or estradiol are responsible for the breast hypertrophy, but studies also have documented decreased levels of plasma progesterone (3). Others speculate that breast hypertrophy results from an exaggerated organ response to minimal concentrations of the estrogens and progesterone that regulate breast growth (2, 3). Infrequently, reactions to drugs such as D-penicillamine may be responsible for the breast hypertrophy. Whatever the cause, the structure of the breast is essentially normal but there is a volume increase in its glandular and connective tissue components (4). In contrast, a hypertrophic breast associated with obesity usually contains more subcutaneous and interglandular fat deposits. For postmenopausal women, hypertrophic breasts are characterized by sagging and replacement of lobular tissue with fat (2).

Women who seek reduction mammoplasty (RM) are primarily interested in having average-sized breasts that are proportional to the rest of their bodies. As an additional benefit of the procedure, many women experience improved physical and psychosocial functioning that leads to an enhanced quality of life. In 2004, 105,592 breast reduction procedures were performed in the United States by board-certified plastic surgeons (1). This number represents a 25% increase since 2000 and will probably continue to rise as plastic surgery in general becomes more socially acceptable. Presently, the literature describes 72 different breast reduction techniques, many of which are variations of techniques first developed in the early 20th century (5). RM procedures have improved over the years as surgeons have developed technical innovations to reduce scarring and improve patient satisfaction.

This chapter will explore the reasons why women seek RM, including the pursuit of relief from the physical symptoms of breast hypertrophy that nonsurgical treatments do not offer. Relief of psychological distress caused by abnormal breast size is similarly important in the minds of many RM patients. The physical and psychological outcomes of breast reduction are then discussed, as are the high levels of patient satisfaction and reasons for dissatisfaction.


The primary preoperative motivations for breast reduction can be loosely classified as either physical or psychological in nature. One prospective study has identified six major areas of concern to women who seek breast reduction: (i) physical activity limitations; (ii) clothes fit and availability; (iii) physical problems and pain; (iv) embarrassment; (v) lack of confidence; and (vi) personal relationships and social life (6). In two large, retrospective studies, 98% to 100% of women endorsed one or more of these factors as the reason that they sought surgery (7, 8). Relief of physical symptoms was reported by 91% and 78% of women in the two studies; self-consciousness about breast size was cited by 78% and 68%; and cosmetic concerns were named by 65%.

Physical Symptoms

One goal of RM is to reduce breast volume and weight, which can cause upper/lower back pain, neck and shoulder pain, breast pain, headaches, and ulnar nerve paresthesia (7,9, 10, 11, 12, 13). Although these symptoms are often trivialized by those who do not have large breasts, preoperative RM patients score higher on standardized pain indexes as compared to persons suffering from arthritis and chronic low back pain (13).

Common physical findings that contribute to discomfort include shoulder grooving from bra straps that support the breast weight (7,9, 10,12, 13, 14, 15), stooped posture (9,14,16), intertrigo beneath the breasts caused by sweating and irritation within the inframammary crease (7, 8, 9, 10,12, 13, 14, 15, 16), and difficulty finding a comfortable sleeping position (8, 9,16). Decreased sensation in the skin, nipple, and/or areola also occurs with some frequency (17, 18, 19). Although not completely understood, two theories are most often postulated as causes of decreased sensation: (i) chronic traction injury to the sensory nerves resulting from the pull of gravity on a heavy breast, and (ii) decreased density of sensory nerve receptors in the expanded nipple-areolar complex (17). Measurable preoperative respiratory difficulties—and their significant improvement after surgery—also have been reported (20, 21).

For some women, the pain associated with breast hypertrophy may be severe enough to interfere with work. For example, 41% of reduction patients in one study had a working disability (on sick leave for some period of time) because of symptom severity (22). In addition, the pain and weight of very large breasts typically leads to reductions in exercise and engagement in everyday living activities, such as housework and playing with children. Studies have found that at least 83% of RM patients have difficulty taking part in physical activity most or all of the time prior to surgery (13,23).

The relationship between body mass and the physical symptoms associated with large breasts is equivocal. Several studies have suggested that the physical symptoms suffered by women who seek RM have been found to be independent of their body mass index (BMI) (9,24, 25). Other studies, however, have found an association between overall body mass and physical symptoms. For example, in comparing obese and non-obese RM patients, Glatt et al. found that obese women were significantly more likely to have neck pain, breast pain, and intertrigo than non-obese patients (14). Netscher et al. compared the physical and psychosocial symptoms of 31 women seeking breast reduction, 21 seeking breast augmentation, and 88 student volunteers who had never thought about breast surgery (26). Not surprisingly, the breast reduction group had a significantly higher mean weight, larger bra cup size, and larger bra circumference size. When all subjects were categorized according to small, medium, or large body mass, bra circumference size, and bra cup size, the large body mass index group was significantly more likely to report only three conditions: back/neck pain, shoulder pain, and rashes. When the women were categorized by
chest circumference, the large size group was significantly different on four conditions: back/neck pain, shoulder pain, rashes, and appearance concerns. When categorized according to bra cup, the large size group was significantly more likely to report back/neck pain, shoulder pain, rashes, breathing problems, tingling/numbness in upper extremities, activity limitations, and reduced exercise participation. Thus, a large bra cup size was associated with more of the physical symptoms of breast hypertrophy than either body mass or bra circumference.

The physical symptoms of macromastia appear to vary by age. Almost half (48%) of breast reduction patients are between the ages of 19 and 34 (1). Thirty-six percent are between 35 and 50 years old, 14% are 18 or younger, and 2% are 51 years old and older. Complaints about physical symptoms are more often voiced by women in their 30s and older, perhaps because of the accumulated years of carrying heavy and disproportionate weight on the chest, which can place unnatural loading on the upper body skeleton and musculature (27). However, studies that looked specifically at teenagers with breast hypertrophy found that large majorities of them—up to 100% in some studies—also reported back, neck, or shoulder pain (28, 29).

Psychological Motivations

Breast hypertrophy may have a profound effect on women’s lives by contributing to heightened self-consciousness, poor self-esteem, decreased confidence, and a negative body image (6,10,16,30, 31, 32). Large breasts can interfere with a woman’s ability to have an active lifestyle and make it difficult to find clothing, swimsuits, or underwear that fit (6,10,16,30, 31, 32). Almost two-thirds of RM patients questioned before surgery “almost always” or “often” felt unattractive, and 40% felt their breast size adversely affected their sex lives (31).

Although younger patients suffer from physical problems, they may be more strongly motivated to have surgery because of psychosocial concerns (29,33). In addition to being the brunt of jokes and teasing comments related to their breast size during their formative years, teenagers may experience a great deal of unwanted attention from their male peers, who tend to pay more attention to their large breasts than see the person behind them (29). Adolescent girls with breast hypertrophy are often unable or embarrassed to wear bathing suits and fashionable clothing commonly worn by their peers (29). As a result, they may adopt strategies to camouflage their breasts, such as wearing baggy clothing, adopting a stooped posture, or intentionally gaining weight. If untreated, the emotional and social repercussions of abnormally large breasts in adolescence may resonate throughout adulthood.

Deliberate weight gain to hide macromastia is not uncommon among young women. Increased breast size also may inhibit a young woman’s ability to engage in regular exercise or organized sports as a way to maintain a healthy lifestyle and normal body weight. While some teenagers choose to gain weight, others may develop eating disorders (34, 35). One study reported on nine young women with bulimia nervosa who wore DD or DDD bra cup sizes by their mid-teens and began binge eating and purging as an inappropriate weight control strategy (35). After RM, eight of the nine had recovered from bulimia, and the one still recovering had reduced her binging and purging episodes by 80% (35).

Several studies have investigated the psychological motivations of RM using a variety of psychometric measures. In particular, quality of life, body image, depressive, and anxiety-related symptoms have received the greatest empirical attention.

Quality of life is a significant concern of women who seek breast reduction. The well-validated and standardized Medical Outcomes Survey Short Form-36 (SF-36) has been used most often to assess the health-related quality of life of breast reduction patients. The SF-36 has eight subscales: physical function, role limitation (physical), role limitation (mental), social function, mental function, vitality and energy, pain, and health perception. Several investigators have compared the
preoperative scores of RM patients with normal controls from the general population and found that patients scored significantly lower than population controls on six (16,30) to all eight quality of life dimensions (11,13,31,36).

Other studies have examined additional psychological symptoms potentially related to breast hypertrophy. Using the Brief Symptom Inventory (BSI), Behmand et al. found that RM candidates had significantly higher ratings for depression, anxiety, interpersonal sensitivity, and hostility when compared to normal controls (36). Scores from preoperative RM patients on the Hospital Anxiety and Depression Scale (HADS) revealed significantly more symptoms of depression and anxiety when compared with an age-matched control group of large-breasted women who did not want surgery (30). The women who wanted surgery also had lower self-esteem and greater interpersonal difficulties than the large-breasted controls (30). Additionally, the surgical patients reported significantly more physical symptoms and limitations than the controls, which may have contributed to the pursuit of surgery.

Sarwer et al. compared the body image concerns of 30 breast reduction patients to 30 women who sought breast augmentation and found greater body image dissatisfaction among RM patients (32). The two groups of patients differed on seven of the ten subscales of the Multidimensional Body-Self Relations Questionnaire (MBSRQ), with preoperative breast reduction patients scoring significantly lower than preoperative augmentation patients on Appearance Evaluation, Body-Areas Satisfaction, Fitness Evaluation, Fitness Orientation, Health Evaluation, Health Orientation and Self-Classified Weight subscales. Using the Body Dysmorphic Disorder Examination-Self-Report (BDDE-SR) (adapted in this study for use as a measure of breast dissatisfaction), they also found that women who sought RM were significantly more dissatisfied with their breasts than women who sought augmentation (32). In addition, reduction patients were significantly more embarrassed about their breasts in public areas and in social settings and more likely to avoid physical activity because of self-consciousness about breast size. Furthermore, a significantly greater number of reduction patients believed their breast appearance was abnormal.

All plastic surgeons must be watchful for patients who may be suffering from psychological disturbances, especially body dysmorphic disorder (BDD) (see Chapters 14 and 16). However, clinical experience suggests that BDD is rarely encountered in women who seek breast reduction. Patients seeking RM have a real physical problem that is readily apparent, and they rarely, if ever, exaggerate its seriousness or its impact on their lives. When the obvious deformity is treated surgically, RM patients are unlikely to become fixated on another body area that they feel needs surgical correction.

The emotional pain and reduced quality of life suffered by women seeking breast reduction can be assessed with a variety of psychometric instruments. These measures can provide both patients and surgeons with a wealth of information about the specific psychosocial concerns experienced by patients prior to surgery. Specific questions in the initial consultation, as shown in Questionnaire 12-1 at the end of this chapter, can provide additional information on the extent of psychological distress resulting from breast hypertrophy. These questions easily can be worked into the surgeon’s typical patient evaluation strategy to ascertain which specific concerns seem to have the greatest impact on prospective patients. They should also help surgeons determine whether a psychiatric consultation might be warranted, especially if a patient’s psychological distress is excessive and inconsistent with the degree of breast hypertrophy observed.


Attempts to treat the physical symptoms of breast hypertrophy without surgery have historically included weight reduction, pain medications (over-the-counter, prescription, and narcotic), heat or cold treatments, hydrotherapy, postural training,
relaxation training, exercise, physical therapy, chiropractic treatments, acupuncture, biofeedback, and the use of supportive bras or braces (10,13,15). In a multicenter prospective study, 179 women were asked to evaluate the extent to which these treatments were effective for alleviating their symptoms (13). Patients were compared with 88 women who also had breast hypertrophy but did not request surgery. Surgical patients were two to three times more likely than controls to have tried nonsurgical treatments with little or no improvement. For example, weight loss was tried by 85% of surgical patients, but no patient reported complete or permanent relief from their symptoms. Similarly, 77% of patients and 40% of controls reported analgesics use, but permanent relief was elusive for both groups. In contrast, surgery was very successful in relieving symptoms in the vast majority of patients (13). Other investigations reached similar conclusions (10,15). When considering the efficacy of nonsurgical treatments, surgeons should be aware that conservative treatments typically offer little, if any, symptom relief or psychological benefit. For most women, breast reduction is a last resort attempt at symptom relief, not the first.

Sep 12, 2016 | Posted by in Reconstructive microsurgery | Comments Off on Breast Reduction
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